what is polst? physician orders for life sustaining treatment

What is POLST?PhysicianOrders for LifeSustainingTreatment

California POLST Education Program© April 2011 Coalition for Compassionate Care of CaliforniaMaterials made possible by a grant from the California HealthCare Foundation

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Why POLST?

1. Patient wishes often are not known.– The Advance Healthcare Directive

(AHCD) may not be accessible.– Wishes may not be clearly defined in

AHCD.

2. Allows healthcare providers to know and honor wishes for end-of-life care.


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Case Study: What We Know


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Case Study: What We Didn’t Know

©California Medical Association 2000-2009


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Case Study: What Happened

AHCD not transferred with patient.

DNR wishes not documented.

Over-treatment against patient wishes.

Unnecessary pain and suffering.


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What is POLST?

A physician order recognized throughout the medical system.

Portable document that transfers with the patient.

Brightly colored, standardized form for entire state of CA.


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What is POLST?

Allows individuals to choose medical treatments they want to receive, and identify those they do not want.

Provides direction for healthcare providers during serious illness.


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Who Would Benefit from Having a POLST Form?

Chronic, progressive illness

Serious health condition

Medically frail

Tool for determination– “You wouldn’t be surprised if this patient

died within the next year.”


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POLST History

POLST development began in Oregon in 1991.

Expanded to more than half of US states.

Developing ProgramsDeveloping Programs*As of January 2011

National POLST Paradigm Programs

Endorsed ProgramsEndorsed Programs

No Program (Contacts)No Program (Contacts) Designation of POLST Paradigm Program status based on information available by the program to the Task Force.


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POLST Success

Oregon study of 180 Skilled Nursing Facility (SNF) patients:– POLST stated No CPR and Comfort

Measures Only.– Patient wishes were honored.

More research available at www.polst.org.


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POLST in California

The Coalition for Compassionate Care of California (CCCC) is lead agency.

Support from California HealthCare Foundation.

Grassroots efforts of local POLST coalitions and communities.


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POLST in California

Effective January 1, 2009


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POLST in California

One form for entire state.

Use not mandated.

Honoring form is mandated.

Provides immunity from civil or criminal liability.


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POLST vs. Advance Healthcare Directive

POLST complements the Advance Healthcare Directive (AHCD).

Both are legal documents.


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POLST vs. Advance Healthcare Directive

POLST AHCD For seriously ill/frail,

at any age

For anyone 18 and older

Specific orders for current treatment

General instructions for future treatment

Can be signed by decisionmaker

Appoints decisionmaker


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Where Does POLST Fit In?

Advance Care Planning Continuum

Complete an Advance Directive

Complete a POLST Form

Age 18

End-of-Life Wishes Honored

Diagnosed with Serious or Chronic, Progressive Illness (at any age)

Update Advance Directive Periodically

CC OO NN VV EE RR SS AA TT II OO NN


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POLST vs. Pre-Hospital DNR(Do Not Resuscitate)

Similarities:– Physician orders.– Address Do Not Resuscitate.– Intended for medically frail or those with

chronic or serious illness.


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POLST vs. Pre-Hospital DNR(Do Not Resuscitate)

POLST Pre-Hospital DNR Allows for choosing

resuscitation

Can only use if choosing DNR

Allows for other medical treatments

Only applies to resuscitation

Honored across all healthcare settings

Only honored outside the hospital


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POLST vs. PIC(Preferred Intensity of Care)

POLST PIC Consistent form for

CA

PIC form is different in every SNF

Is a medical order Is not a medical order; similar to a doctor’s note

Honored across all healthcare settings

Only honored within the SNF


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POLST vs. PIC(Preferred Intensity of Care)

Both include choices for medical interventions.

POLST can replace the PIC form at SNF.


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CA POLST Form – Front Side


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Section A: CPR


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Section B: Medical Interventions


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Diagram of POLST Medical Interventions

CPR

Full Treatment*

DNR

Comfort Measures

Limited Interventions

*Consider time/prognosis factors under “Full Treatment” “Defined trial period. Do not keep on prolonged life support.”


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Section C: Artificial Nutrition


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The POLST Conversation

POLST is not just a check-box form.

The POLST conversation provides context for patients/families to:– Make informed choices.– Identify goals of treatment.


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Section D: Information and Signatures


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Who Can Speak for the Patient?

Surrogate decisionmaker/agent

Parent, guardian, conservator

Closest available relative


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CA POLST Form – Back Side


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Who Can Help Complete POLST?

Healthcare providers – “licensed, certified, or otherwise authorized to provide healthcare in the normal course of business.”

Best practice suggests use of those trained in the POLST Conversation:– Physicians– Nurses– Social Workers– Chaplains– Social Service Designees


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Directions – Completing POLST


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Directions – Using POLST


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Directions – Reviewing/Modifying/Voiding POLST


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When Should POLST be Reviewed?

Transfer from one care setting to another.

Change in patient’s health condition.

Patient’s treatment preferences change.

Patient Care Conference.


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Can POLST be Changed?

Individual with capacity can request alternative treatment or revoke a POLST at anytime.

Legally recognized decisionmaker may request change based on condition change or new information regarding patient wishes.


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Original pink POLST stays with patient

At SNF/Hospital:– File in medical chart (with AHCD).– Send original with patient upon return to

home/SNF/hospital.– Keep copy if resident transferred; review

POLST upon resident’s return.

Where Should We Keep POLST?


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At home:– Post in easy-to-find location (with AHCD).– Give to EMS to transport with patient.

Where Should We Keep POLST?


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POLST: Depth of the Process

POLST is more than a form.

POLST:– Facilitates rich conversations with

patients/families.– Complements the AHCD.– Incorporates the depth of comfort care.


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California POLST Project

C oalition for

The Coalition for Compassionate Care of California (CCCC) providesleadership and oversight for POLST outreach activities in California, with support from the California HealthCare Foundation.

C ompassionate

C are of

C alifornia


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POLST Conversation

A rich conversation with each individual patient

Comprehensive Education

To promote excellent conversational skills with patients and families

Consistent Form

Standardized form recognized across care settings

Translating an individual’s wishes for care during serious or chronic illness into medical orders that honor those preferences for medical treatment.

Community Collaboration

Integrating POLST into the community standard of care

California POLST Project


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California POLST Form

Available at www.caPOLST.org– Translations available

May be purchased from:– www.med-pass.com

(bulk forms/paper)– www.cmanet.org

(POLST Kit)

©California Medical Association 2009


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California POLST Form

Print on Ultra Pink, 65# card stock paper Copies/faxes on any color paper are

acceptable

Focus on the conversation


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POLST Resources

Provider and Consumer Brochures

FAQs

Videos


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POLST Resources

Model policies and procedures

Standardized educational curriculum

Local POLST coalitions

www.caPOLST.org

Questions?

what is polst? physician orders for life sustaining treatment

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